Healthcare Provider Details

I. General information

NPI: 1659634350
Provider Name (Legal Business Name): BLACK HEALTH COALITION OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 W VLIET ST
MILWAUKEE WI
53208-2461
US

IV. Provider business mailing address

3020 W VLIET ST
MILWAUKEE WI
53208-2461
US

V. Phone/Fax

Practice location:
  • Phone: 414-933-0064
  • Fax: 414-933-0084
Mailing address:
  • Phone: 414-933-0064
  • Fax: 414-933-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA MCMANUS
Title or Position: PRESIDENT/CEO
Credential: PH.D., RN
Phone: 414-933-0064